Ahip 2025 Module 3 Medicare
Prescription Drug Coverage Questions
and Correct Answers
Mrs. Roswell is a new Medicare beneficiary who has just retired from retail work. She is interested in
selecting a Medicare Part D prescription drug plan. She takes several medications and is concerned
that she has not been able to identify a plan that covers all of her medications. She does not want to
make an abrupt change to new drugs that would be covered and asks what she should do. What
should you tell her? - Answer Every Part D drug plan is required to cover a single one-month fill of
her existing medications sometime during a 90-day transition period.
What types of tools can Medicare Part D prescription drug plans use that affect the way their
enrollees can access medications? - Answer INCORRECT Part D plans do not have to cover all
medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In
addition, they can use cost containment techniques such as tiered co-payments and prior
authorization.
Mr. Hildalgo complains to you that because he takes multiple expensive drugs, he has trouble paying
his cost sharing for his prescription drugs, particularly at the beginning of the year during the
deductible phase. He is happy with his plan and does not want to change. However, he said he had
heard about a new program called the Medicare Prescription Payment Plan and asked whether it
might help. What do you tell him? - Answer The Medicare Prescription Payment Plan helps spread
out beneficiary cost-sharing payments but does not decrease the total amount owed.
Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is concerned
about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but
does not want to purchase extra coverage that he will not need. What should you tell him? - Answer
If the drug coverage he has is not expected to pay, on average, at least as much as Medicare's
standard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his
initial eligibility period to avoid the late enrollment penalty.
One of your clients, Lauren Nichols, has heard about a Medicare concept from one of her neighbors
called TrOOP. She asks you to explain it. What do you say? - Answer
Mr. Zachow has a condition for which three drugs are available. He has tried two but had an allergic
reaction to them. Only the third drug works for him and it is not on his Part D plan's formulary. What
could you tell him to do? - Answer Mr. Zachow has a right to request a formulary exception to obtain
coverage for his Part D drug. He or his physician could obtain the standardized request form on the
plan's website, fill it out, and submit it to his plan.
Prescription Drug Coverage Questions
and Correct Answers
Mrs. Roswell is a new Medicare beneficiary who has just retired from retail work. She is interested in
selecting a Medicare Part D prescription drug plan. She takes several medications and is concerned
that she has not been able to identify a plan that covers all of her medications. She does not want to
make an abrupt change to new drugs that would be covered and asks what she should do. What
should you tell her? - Answer Every Part D drug plan is required to cover a single one-month fill of
her existing medications sometime during a 90-day transition period.
What types of tools can Medicare Part D prescription drug plans use that affect the way their
enrollees can access medications? - Answer INCORRECT Part D plans do not have to cover all
medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In
addition, they can use cost containment techniques such as tiered co-payments and prior
authorization.
Mr. Hildalgo complains to you that because he takes multiple expensive drugs, he has trouble paying
his cost sharing for his prescription drugs, particularly at the beginning of the year during the
deductible phase. He is happy with his plan and does not want to change. However, he said he had
heard about a new program called the Medicare Prescription Payment Plan and asked whether it
might help. What do you tell him? - Answer The Medicare Prescription Payment Plan helps spread
out beneficiary cost-sharing payments but does not decrease the total amount owed.
Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is concerned
about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but
does not want to purchase extra coverage that he will not need. What should you tell him? - Answer
If the drug coverage he has is not expected to pay, on average, at least as much as Medicare's
standard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his
initial eligibility period to avoid the late enrollment penalty.
One of your clients, Lauren Nichols, has heard about a Medicare concept from one of her neighbors
called TrOOP. She asks you to explain it. What do you say? - Answer
Mr. Zachow has a condition for which three drugs are available. He has tried two but had an allergic
reaction to them. Only the third drug works for him and it is not on his Part D plan's formulary. What
could you tell him to do? - Answer Mr. Zachow has a right to request a formulary exception to obtain
coverage for his Part D drug. He or his physician could obtain the standardized request form on the
plan's website, fill it out, and submit it to his plan.
